Stamp Duty Paid PRIVATE CAR SCHEDULE

Setem Hasil Dibayar JADUAL KERETA PERSENDIRIAN

The Insured / Pihak Diinsuranskan Policy No / Master Policy No.
MA227332
No Polisi / No Polisi Induk
LEE KONG CHENG
20-5-7 PANGSAPURI SRI JINJANG JALAN
19/32 TAMAN JINJANG BARU Account No. / Agent's Name HT - 10003108
52000 KUALA LUMPUR No. Akaun / Nama Ejen AGENT - THONG BENG HONG
WP KUALA LUMPUR
Date of Proposal or Declaration
Tarikh Tandatangan Cadangan atau Akuan 18-09-2018 01:12:31 PM

Geographical Area /Kawasan Geografi: Malaysia, Republic of Singapore and Negara Brunei Darussalam
Occupation Agreed Value
OTHER OCCUPATION RM 14,000.00
Pekerjaan Nilai yang dipersetujui

NRIC / Business Reg. / Others ID Trailer Sum Insured RM 0.00

No K/P Baru/No Pendaftaran Perniagaan / 780831-14-5367 Jumlah Treler Diinsuranskan
ID Lain-lain

Nationality Compulsory Excess / Ekses Wajib RM 400.00

MALAYSIAN
Warganegara Voluntary Excess / Ekses RM 0.00
Period Insurance / Tempoh Insurans Cover Type COMPREHENSIVE
From/Dari 20-09-2018 12:00:01 AM To /Hingga 19-09-2019 Jenis Perlindungan

Basic Premium RM 672.98

Class of Vehicle PRIVATE VEHICLE - EXCLUDING
Premium Asas
Kelas Kenderaan GOODS
No-Claim-Discount(NCD)(55.00%) RM 370.14
Hire Purchase - Diskaun Tanpa Tuntutan(DTT)
Sewa Beli NCD Effective Date (20-09-2018)
Tarikh Berkuatkuasa DTT
Trailer Premium RM 0.00
Regn. Card No./Trailer Regn. Card No. Premium Treler
No. Perakuan Pendaftaran -
Kenderaan/Trailer

RM 302.84
Registration No.
WSP3909
No. Pendaftaran Kenderaan

Trailer Registration No.

No. Treler - Optional Add-on:
Manfaat Tambahan:

Make & Type Of Body PROTON SAGA / 4D SEDAN NAMED DRIVER(S) RM 10.00
Buatan & Jenis Badan

RM 10.00
Cubic Capacity
Keupayaan Enjin 1332 CC
Total Premium RM 312.84
Jumlah Premium
Year of Manufacture
2009 Service Tax (6.00%) RM 18.77
Tahun Diperbuat
Cukai Perkhidmatan
Stamp Duty RM 10.00
Seating Capacity(including driver) Setem Hasil
Muatan Tempat Duduk Termasuk Pemandu 5

Engine No.
34PEP53683
No. Enjin

Chassis No.
No. Casis PL1BT3SNR98091231

Trailer Chassis No.

-
No. Casis Treler
Named Driver(s) Total Amount Payable RM 341.61
Pemandu yang Diberi Kuasa Jumlah Perlu Dibayar
THE POLICY HOLDER Act RM 54.13
Akta
LEE KIM MENG (510225-06-5199)

KHOR PAU CHOO (570725-08-5860)

Limitation as to use: As per Certificate of Insurance attached / Had Penggunaan: Seperti Sijil Insuran yang disertakan
Subject to following clauses printed herein or attached hereto / Tertakluk kepada fasal-fasal dicetak atau dikepil disini
87

Page 1 18-09-2018 01:12:36 PM

LEGISLATION/PERUNDANGAN:
Road Transport Act, 1987(Malaysia) Motor Vehicles (Third-Party Risks and Compensation) Act (Cap 189) Republic of Singapore Motor Vehicles (Third Party Risks and Compensation) Rules (Republic of
Singapore) Motor Vehicles Insurance (Third Party Risks) Act (Cap 90) Negara Brunei Darussalam (the reference to legislation under the heading)"Avoidance of Certain Terms and Rights of Recovery is limited
to Section 94, 95 and 96 of the Road Transport Act 1987 (Malaysia) Section7,8 and 9 of the Motor Vehicles (Third Party Risks and Compensation) Act (Cap 189) Republic of Singapore and Section 7 of the
Motor Vehicles Insurance (Third Party Risks) Act (Cap 90) Negara Brunei Darussalam.

Important Notice: For environmental conservation, policy documents may no longer be printed out (unless necessary or upon request) but may be produced and delivered to you in an
electronic form or provided and displayed to you online through our official website at www.berjayasompo.com.my.Please also check our website for any update or changes to your
insurance policy which may be notified and published from time to time. For more information, please call our customer service at 1-800-889-933.

You are required to read your Policy Schedule together with the Policy Wording for the terms and conditions of your insurance policy, including the extent of coverage and exclusions as
well as endorsements, if applicable. Please refer to the Policy Wording on our website at the Download Library Section (http://www.berjayasompo.com.my/page/download-library#p-2 )
which you can also download for your copy and perusal. If you are unable to access our website or refer or obtain the Policy Wording, please contact us or our servicing agent
immediately for assistance and we shall provide you with the same. You may also request for a printed copy from any of our branch offices located nationwide.

Nota penting: Untuk kepentingan alam sekitar, dokumen-dokumen polisi tidak akan dicetak (kecuali sekiranya perlu atau atas permintaan) tetapi boleh dikeluarkan dan diserahkan
kepada anda di dalam bentuk elektronik atau disediakan dan dipaparkan kepada anda atas talian melalui laman web rasmi kami di www.berjayasompo.com.my.Sila rujuk laman web
kami untuk sebarang perubahan atau maklumat terkini berkenaan polisi insurans anda yang boleh dimaklumkan dan diterbitkan dari masa ke semasa. Untuk maklumat lanjut, sila
menghubungi khidmat pelanggan kami di 1-800-889-933.

Anda dikehendaki untuk membaca Jadual Polisi ini bersamaan dengan Kandungan Polisi untuk terma dan syarat polisi insurans anda, termasuk had perlindungan, pengecualian-
pengecualian dan pengendorsan, dimana terpakai. Sila rujuk kepada Kandungan Polisi dalam laman web kami di Bahagian Perpustakaan (http://www.berjayasompo.com.
my/page/download-library#p-2 ) yang boleh dimuat-turun oleh anda untuk salinan dan penelitian anda. Sekiranya anda tidak dapat memasuki laman web kami atau merujuk atau
memperolehi Kandungan Polisi tersebut, sila berhubung dengan kami atau ejen kami dengan segera untuk bantuan supaya kami dapat memberikan salinan kepada anda. Anda juga
boleh membuat permintaan untuk mendapatkan satu salinan cetak dari mana-mana cawangan pejabat kami di seluruh negara.

***THIS IS A COMPUTER GENERATED DOCUMENT AND IT DOES NOT REQUIRE SIGNATURE.***

THIS DOCUMENT SHALL NOT BE INVALIDATED SOLELY ON THE GROUND THAT IT IS NOT SIGNED.
***INI ADALAH DOKUMEN YANG DIKELUARKAN OLEH KOMPUTER DAN TANDATANGAN TIDAK DIPERLUKAN.*** DOKUMEN
INI TIDAK HARUS DITAKSAHKAN SEMATA-MATA ATAS ALASAN IA TIDAK DITANDATANGANI.

1234PL781801-1 Renewal of Policy No. : -

Page 2 18-09-2018 01:12:36 PM

 CERTIFICATE OF INSURANCE / SIJIL INSURANS
ROAD TRANSPORT ACT, 1987 (MALAYSIA)
MOTOR VEHICLES(THIRD PARTY RISKS) RULES, 1959 (MALAYSIA)
MOTOR VEHICLES(THIRD PARTY RISKS & COMPENSATION) ACT (CAP, 189) (REPUBLIC OF SINGAPORE)
MOTOR VEHICLES(THIRD PARTY RISKS & COMPENSATION) RULES (REPUBLIC OF SINGAPORE)
MOTOR VEHICLES INSURANCE (THIRD PARTY RISKS) ACT (CAP, 90) NEGARA BRUNEI DARUSSALAM
C.I. Code / Kod Sijil Insurans : MX1

CERTIFICATE NO. / NO. SIJIL : MA227332

1. Index Mark and Registration Number of Vehicle / Tanda Indek dan Nombor Pendaftaran Kenderaan : WSP3909

2. Name of Policyholder / Nama Pemegang Polisi : LEE KONG CHENG

3. Effective Date of the Commencement of Insurance for purposes of the Regulations, Ordinance or Enactment : 20-09-2018 12:00:01 AM
Tarikh berkuatkuasa bagi Permulaan Insuran Untuk tujuan Peraturan, Ordinan atau Enakmen

4. Date of expiry of the Insurance / Tarikh Tamat Insuran : 19-09-2019

5. Persons or Classes of persons entitled to drive* / Orang atau Kelas Orang yang layak memandu*

(a) The Policyholder.

(b) Any other person who is driving on the Policyholder's order or with his permission. /
(a) Pemegang Polisi.
(b) Sesiapa yang memandu atas arahan Pemegang Polisi atau dengan kebenarannya

Provided that the person driving is permitted in accordance with the licensing or other laws or regulation to drive the Motor Vehicle or has been so permitted and is not
disqualified by order of a Court of Law or by reason of any enactment or regulation in that behalf from driving the Motor Vehicle.
Dengan syarat orang tersebut dibenarkan memandu menurut undang-undang perlesenan atau undang-undang lain atau peraturan untuk memandu kenderaan Bermotor tersebut
atau telah dibenarkan dan tidak dilucutkan kelayakannya di atas perintah Mahkamah atau oleh sebab mana-mana enakmen atau peraturan daripada memandu Kenderaan
Bermotor tersebut.
6. Limitations as to use* / Had Penggunaan*
Use only for social, domestic and pleasure purposes and for the Policyholder's business.
The Policy does not cover use for hire or reward, racing, pacemaking, reliability trial, speed-testing, the carriage of goods other than samples in
connection with any trade or business. /
Digunakan hanya untuk tujuan sosial, domestik dan persiaran dan untuk perniagaan Pemegang Polisi.
Polisi ini tidak melindungi kegunaan untuk sewaan atau ganjaran, perlumbaan, mengkadar kelajuan, ujian kebolehpercayaan, ujian kelajuan, membawa
barangan selain daripada sampel yang berkaitan dengan apa-apa pekerjaan atau perniagaan.

*Limitations rendered inoperative by Section 95 of the Road Transport Act 1987 (Malaysia) or Section 8 of the Motor Vehicles (Third Party Risks and Compensation) Act (Cap 189)
Republic of Singapore or Section 7 of the Motor Vehicles Insurance (Third Party Risks) Act (Cap 90) Negara Brunei Darussalam are not included under this heading.
Pengehadan dijadikan tidak berkuatkuasa oleh Seksyen 95 Akta Pengangkutan Jalan 1987 (Malaysia) atau Seksyen 8 of the Motor Vehicles (Third Party Risks and Compensation) Act (Cap 189)
Republic of Singapore or Section 7 of the Motor Vehicles Insurance (Third party Risks) Act (Cap 90) Negara Brunei Darussalam tidak termasuk di bawah tajuk ini.
I/We hereby certify that this covering note is issued in accordance with the provision of Part IV of the Road Transport Act 1987 (Malaysia) and The Motor Vehicles (Third Party Risks and Compensation) Act
(Republic of Singapore) The Motor Vehicles Insurance (Third Party Risks) Act (Cap 90) Negara Brunei Darussalam.

***THIS IS A COMPUTER GENERATED DOCUMENT AND IT DOES NOT REQUIRE SIGNATURE.***

THIS DOCUMENT SHALL NOT BE INVALIDATED SOLELY ON THE GROUND THAT IT IS NOT SIGNED.
***INI ADALAH DOKUMEN YANG DIKELUARKAN OLEH KOMPUTER DAN TANDATANGAN TIDAK DIPERLUKAN.***
DOKUMEN INI TIDAK HARUS DITAKSAHKAN SEMATA-MATA ATAS ALASAN IA TIDAK DITANDATANGANI.

1234PL781801-1

Page 3 18-09-2018 01:12:36 PM

 Privacy Notice

The Personal Data you have provided to us will be processed for the purpose of processing your insurance application/proposal, provision of
insurance related products or services or any addition, alteration, variation, cancellation, renewal or reinstatement thereof, performing
statistical/actuarial research or data study, promoting products and services and other related purposes.

Although you are not obliged to provide us with your Personal Data, we will not be able to process your application for insurance cover or
process your claim if you fail to provide all requested information.

Your Personal Data may be disclosed to any related company or any other company carrying on insurance or reinsurance related business or
an intermediary or a claims or investigation or other service provider and to any association, federation or similar organisation of insurance
companies that exists or is formed from time to time for the Purpose or to fulfil some legal or regulatory function or is reasonably required in
the interest of the insurance industry.

We may also disclose your Personal Data where such disclosure is required under the law, court orders or pursuant to guidelines issued by
regulatory or other relevant authorities, if we reasonably believe that we have a lawful right to disclose your Personal Data to any third party
or that we would have had your consent for such disclosure if you had known of the same, and/or if the disclosure is in the public interest.

Please be informed that your Personal Data may also be transferred to any of our related companies which may be located outside Malaysia
for the Purpose.In the event that we use external service providers, specific security and confidentiality safeguards have been put in place to
ensure your privacy rights remain unaffected.

You may make inquiries, complaints or request for access to or correction of your Personal Data or limit the processing of your Personal Data at any time
hereafter by submitting such request to us via email at info@berjayasompo.com.my or mailing it to our Customer Service Centre, Level 36, Menara Bangkok
Bank,105, Jalan Ampang,50450 Kuala Lumpur.

We trust that you will consent and agree to the terms above with respect to the processing of your Personal Data. If we do not receive
any response from you on the above, we shall assume that you are agreeable to the same**.

** where sensitive personal data is being processed (i.e. medical history, religious beliefs, political opinions and the commission or alleged
commission of any offence), and personal data is used for cross-selling within Berjaya Sompo Insurance Berhad (BSIB) or by our Group
Companies, this privacy notice must be signed and returned to us.

CONSENT TO USE SENSITIVE PERSONAL DATA AND FOR CROSS-SELLING WITHIN BSIB OR BY OUR GROUP COMPANIES

I have read and understood the terms of this Privacy Notice and hereby consent to BSIB for the processing of my Sensitive Personal Data for
the purposes described above and for cross-selling within BSIB or by their Group Companies.

Signature Policyholders Full Name : LEE KONG CHENG

Date : 18-09-2018 NRIC/Passport No. : 780831-14-5367

Policy No. : MA227332 Vehicle No. : WSP3909

Page 4 18-09-2018 01:12:36 PM

 Notis Privasi

Data Peribadi anda akan diproses untuk tujuan memproses permohonan/cadangan insurans, penyediaan produk atau perkhidmatan
berkaitan insurans atau sebarang penambahan, pindaan, perubahan, pembatalan, pembaharuan dan penyambungan, pelaksanaan
penyelidikan statistik/aktuari atau kajian data,promosi produk dan perkhidmatan dan untuk tujuan lain yang berkaitan.

Walaupun anda tidak diwajibkan untuk memberi kami Data Peribadi anda, kami tidak dapat memproses permohonan anda untuk
perlindungan insurans atau memproses tuntutan jika anda tidak memberikan semua maklumat yang diminta.

Data Peribadi anda mungkin didedahkan kepada mana-mana syarikat berkaitan atau mana-mana syarikat lain yang menjalankan perniagaan
berkaitan insurans semula atau syarikat perantara atau tuntutan atau penyiasatan atau penyedia perkhidmatan lain dan kepada mana-mana
persatuan, persekutuan atau organisasi syarikat insurans serupa yang wujud atau yang ditubuhkan dari masa ke masa untuk Tujuan tersebut
atau untuk memenuhi fungsi perundangan atau peraturan atau diperlukan dengan sewajarnya demi kepentingan industri insurans.

Kami juga mungkin mendedahkan Data Peribadi anda apabila pendedahan sedemikian diperlukan di bawah undang-undang, atas arahan
mahkamah atau menurut garis panduan yang dikeluarkan oleh pihak berkuasa kawal selia atau pihak berkuasa lain, jika kami percaya bahawa
kami mempunyai hak di bawah undang-undang untuk mendedahkan Data Peribadi anda kepada mana-mana pihak ketiga atau mungkin akan
mendapatkan persetujuan bagi pendedahan tersebut jika anda mengetahui tentangnya, dan/atau jika pendedahan adalah berasaskan
kepentingan umum.

Anda dimaklumkan bahawa Data Peribadi anda juga boleh dipindahkan kepada mana-mana syarikat berkaitan kami yang mungkin terletak di
luar Malaysia untuk Tujuan tersebut. Sekiranya kami menggunakan penyedia perkhidmatan luar, langkah keselamatan dan kerahsiaan
tertentu diambil untuk memastikan hak kerahsiaan anda tidak terjejas.

Anda boleh membuat pertanyaan, aduan atau permintaan untuk mendapatkan atau membetulkan Data Peribadi anda atau mengehadkan
pemprosesan Data Peribadi pada bila-bila masa selepas itu dengan mengemukakan permintaan tersebut menerusi emel ke
info@berjayasompo.com.my atau menghantar surat ke Pejabat Khidmat Pelanggan, Level 36, Menara Bangkok Bank,105, Jalan Ampang,
50450 Kuala Lumpur.
Kami yakin bahawa anda akan memberikan kebenaran dan bersetuju dengan terma di atas berkaitan dengan pemprosesan Data
Peribadi anda.Jika kami tidak menerima sebarang jawapan daripada anda mengenai perkara di atas, kami mengandaikan bahawa
anda bersetuju dengannya.**
** sekiranya data peribadi sensitif diproses (iaitu maklumat tentang kesihatan atau keadaan fizikal atau mental seseorang, pendapat politik,
kepercayaan agama atau kepercayaan lain yang bersifat seumpamanya, pelakuan atau pengataan pelakuan apa-apa kesalahan olehnya) dan
berhasrat menggunakan data peribadi anda untuk tujuan jualan silang oleh Berjaya Sompo Insurance Berhad (BSIB) atau gabungan syarikat-
syarikat kami, kebenaran nyata perlu diperolehi - iaitu notis privasi ini mesti ditandatangani dan dipulangkan kepada kami.

PERAKUAN DAN PERSETUJUAN UNTUK PEMPROSESAN DATA PERIBADI SENSITIF DAN UNTUK JUALAN SILANG OLEH BSIB ATAU
GABUNGAN SYARIKAT-SYARIKAT KAMI
Saya telah membaca dan memahami terma dan syarat Notis Privasi ini dan bersetuju membenarkan BSIB memproses maklumat Data Peribadi
Sensitif saya seperti yang dinyatakan di atas dan juga untuk tujuan jualan silang oleh BSIB atau gabungan syarikat-syarikat mereka.

Tandatangan Pemegang Polisi Nama Penuh Pemegang Polisi : LEE KONG CHENG

Tarikh : 18-09-2018 No. NRIC/Passport No. : 780831-14-5367

No. Polisi : MA227332 No. Plat Kenderaan : WSP3909

Page 5 18-09-2018 01:12:36 PM

Notice to Private Car Comprehensive Policyholders

We are pleased to advise that we have implemented the following initiatives with the aim to serve our policyholders better:

1) Direct Repairs Service Quality workshops (DRS Quality workshops)

In the unfortunate event that your car met with an accident which gives rise to a claim for repairs, you now have an additional choice of sending your car to
our panel of DRS Quality workshops. These DRS Quality workshops are an addition to our current panel of collision repair workshops. These DRS Quality
workshops are quality collision repair centres. Presently, our DRS Quality workshops are located at certain areas only and will be available nationwide in
the near future.

Please note that you still have a choice of sending your car to our current panel of collision repair workshops, instead of these DRS Quality workshops, if
that’s more convenient for you. For more information on these DRS Quality workshops and their services as well as our current panel of collision repair
workshops, please visit our website at www.berjayasompo.com.my.

2) Windscreen Repairs and Replacement Centres (WRRC)

For the benefit of our policyholders, we have also set up a panel of Windscreen Repairs and Replacement Centres to serve you in the unfortunate event
that your car’s windscreen or window glass is damaged. You are not required to make any payment (depending on whether the sum insured of your car’s
windscreen is adequate or not) or lodge a police report. There are 141 centres located throughout the country that provide these services. For more
information on the location of these centres, please visit our website at www.berjayasompo.com.my.

You may also repair or replace your damaged windscreen or window glass at our panel of collision repair workshops or DRS Quality workshops. They too
offer there services to you similarly on a ‘cashless’ basis and you are exempted from having to lodge a police report. However, should you choose to repair
or replace your damaged windscreen or window glass outside of the above panel of Windscreen Repairs and Replacement Centres, or outside of our
panel of collision repair workshops or DRS Quality workshops, then a police report is required.

3) Rakan Auto

We provide Rakan Auto Services to our comprehensive motor insurance policyholders that offers 24-hour emergency roadside assistance.To enjoy our
Rakan Auto benefits, you are required to contact our Rakan Auto 24-hour Call Centre at 03-7628 3822/03-7841 5660 for any emergency roadside
assistance.

Benefits

24-hour Emergency Towing Services Following an Accident

In the event of your car being immobilised following an accident, arrangements will be made by our Call Centre with a member of our approved panel
workshop nearest to you to tow your car for repairs*. Towing charges will be imposed should your car be towed to any workshop other than our panel of
approved workshops.

24-hour Emergency Breakdown and Minor Roadside Repair Services

Should your car break down, our Call Centre will arrange for roadside repairs and if that cannot be carried out, arrangements can be made to tow your car
to an approved workshop for repairs. We will bear the cost up to RM300 per incident for towing and labour cost for roadside repairs. Cost of parts and toll
charges are excluded, and must be settled by the policyholder directly with the workshop.

Important Notes:

(i) You are advised to keep the Call Centre’s telephone number handy by affixing Berjaya Sompo Rakan Auto sticker onto your car’s
windscreen.
(ii) If you do not call Rakan Auto for assistance, you are deemed to have waived your right to such services offered by us and therefore you have
to bear all charges and expenses incurred by using other service providers.

If you have any further queries, kindly contact us at 1800 889 933, or log on to www.berjayasompo.com.my, or visit any of our offices nationwide.

*Charges incurred for repairs will be claimed under your Private Car Comprehensive Policy.

Thank you.

Page 6 18-09-2018 01:12:36 PM

 NOTICE TO ALL POLICYHOLDERS / NOTIS KEPADA SEMUA PEMEGANG POLISI

If you have any complaints relating to this insurance policy, please contact our local branch manager or our complaints unit officer at:
Jika anda mempunyai aduan berhubung dengan polisi insurans ini, sila hubungi pengurus cawangan kami atau pegawai unit aduan di:

COMPLAINTS UNIT /UNIT ADUAN

CUSTOMER SERVICE CENTRE
BERJAYA SOMPO INSURANCE BERHAD
Level 36, Menara Bangkok Bank,
105, Jalan Ampang,
50450 Kuala Lumpur.
Tel./ Tel. : 03-2170 7300
Fax/ Faks : 03-2170 4800
Toll Free No. /Talian Bebas Tol: 1-800-889-933
E-mail/ E-mel: info@berjayasompo.com.my

Or / Atau

The following bodies who are authorised to oversee public enquiries and complaints on insurance related matters:
Pihak-pihak yang diberi kuasa untuk mengendalikan soalan-soalan umum dan pengaduan mengenai perkara-perkara berkenaan insurans:

1. OMBUDSMAN FOR FINANCIAL SERVICES / OMBUDSMAN PERKHIDMATAN KEWANGAN

Level 14, Main Block, Menara Takaful Malaysia
No. 4, Jalan Sultan Sulaiman
50000 Kuala Lumpur
Tel./ Tel.: 03 - 2272 2811
Fax/ Faks: 03 - 2272 1577
E-mail/ E-mel: enquiry@ofs.org.my
Website/ Laman Web: www.ofs.org.my

2. LAMAN INFORMASI NASIHAT DAN KHIDMAT (LINK)

Pengarah
Jabatan LINK & Pejabat Wilayah
Bank Negara Malaysia
P.O Box 10922
50929 Kuala Lumpur
Tel./ Tel.: 1-300-88-5465
Fax/ Faks: 03-2174 1515
E-mail/ E-mel: bnmtelelink@bnm.gov.my

Page 7 18-09-2018 01:12:36 PM

 LETTER OF UNDERTAKING / SURAT AKUJANJI

NCD Entitlement / Kelayakan Diskaun Tanpa Tuntutan

Previous Vehicle No. / No. Kenderaan Lama:WSP3909
I/C No. (Old) / No. Kad Pengenalan(Lama): (New) / (Baru):780831-14-5367
Business Registration No. / No. Pendaftaran Syarikat: -

I am currently holding a valid * Comprehensive/Third Party motor policy with BERJAYA SOMPO INSURANCE BHD(current Insurer)
Pada masa ini,saya memegang polisi motor * Komprehensif/Pihak Ketiga yang sah dengan BERJAYA SOMPO INSURANCE BHD(penanggung insurans sekarang).

I intend to transfer or claim my 55.00% NCB entitlement to a vehicle No. WSP3909 to be insured with You or purchase a policy from Your Company.
Saya ingin memindahkan atau menuntut 55.00% Kelayakan Diskaun Tanpa Tuntutan saya ke kenderaan bernombor WSP3909 untuk diinsuranskan dengan Anda atau
membeli polisi daripada syarikat Anda.
I hereby confirm that / Saya dengan ini mengesahkan bahawa:-

(a) to the best of my knowledge I have not been involved in an accident in which a claim or Court Action has been lodged/pending or is likely to be taken against me under the
policy.
Dalam pengetahuan saya, saya tidak pernah terlibat dalam sebarang kemalangan di mana ada tuntutan atau Tindakan Makhamah telah dibuat/belum selesai atau
kemungkinan akan diambil terhadap saya dibawah polisi ini

(b) there is no breach of any policy condition(s) which affects my NCD entitlement.
tiada perlanggaran pada mana-mana syarat polisi yang boleh menjejaskan kelayakan Diskaun Tanpa Tuntutan saya.

(c) I have not and shall not use this entitlement of NCD for any other vehicle/policy.
Saya belum dan tidak akan menggunakan kelayakan Diskaun Tanpa Tuntutan ini untuk mana-mana kenderaan/polisi yang lain.

(d) if the NCD is incorrect, I undertake to pay the difference of premium within 14 working days, failing which I agree the policy may be cancelled by the company.
Sekiranya Diskaun Tanpa Tuntutan ini tidak betul, saya memberi akujanji untuk membayar balik perbezaan premium dalam masa 14 hari bekerja, sekiranya gagal berbuat
demikian, saya bersetuju polisi saya dibatalkan oleh Syarikat.

Applicable if NCD is given before confirmation with the ISM NCD Database.
Diguna pakai sekiranya Diskaun Tanpa Tuntutan telah diberikan sebelum mendapat pengesahan dari Pengkalan Data NCD ISM.
1. Enclosed is a copy of *(Original Policy Schedule/Renewal Notice issued by insurance company/Endorsement/Certificate of Insurance) as evidence of my entitlement.
Ditampirkan sesalinan *(Jadual Polisi Asal/Notis Pembaharuan yang dikeluarkan oleh syarikat insurans/Pengendorsan/Sijil Insurans) sebagai bukti kelayakan saya.

2. If the transfer of NCD is between two different vehicles, please enclose the relevant Cancellation/Recovery NCD Endorsement for verification.
Jika pemindahan Diskaun Tanpa Tuntutan adalah antara dua kenderaan berasingan, sila lampirkan Pengendorsan Pembatalan/Pengembalian Balik Diskaun Tanpa
Tuntutan berkenaan untuk pengesahan.

Insured Signature/Tandatangan Pihak Diinsuranskan

(if the Insured is a company, authorised signature(s) and chop)
(jika pihak diinsuranskan adalah syarikat, tandatangan berserta dengan cop)

Note/Nota:

NCD from Overseas / Diskaun Tanpa Tuntutan daripada Luar Negara

Duly Signed Letter of Undertaking and the original NCD confirmation letter stating the number of claim free years must be submitted.
Surat Akujanji yang ditandatangani sewajarnya dan surat pengesahan asal Diskaun Tanpa Tuntutan yang menyatakan bilangan tahun bebas tuntutan mestilah disertakan.

*delete whichever is not appropriate / *Potong yang mana tidak berkenaan.

DECLARATION BY OFFICER/INTERMENDIARY UNDER SECTION 16(2) OF THE ANTI MONEY LAUNDERING ACT 2001
I confirm I have sighted the Original National Registration ldentity Card / Business Registration and verified the identity of the Proposer.

PERAKUAN OLEH PEGAWAI/PENGANTARA DIBAWAH SEKSYEN 16(2) AKTA PENCEGAHAN PENGUBAHAN WANG HARAM 2001
Saya mengesahkan saya telah melihat Kad Pengenalan / Pendaftaran Syarikat yang asal dan menentusahkan identiti Pencadang.

Date / Tarikh Signature of Agent /Tandatangan Ejen

Name / Nama

Page 8 18-09-2018 01:12:36 PM

 CONSUMER MOTOR INSURANCE PROPOSAL FORM
BORANG CADANGAN KENDERAAN BERMOTOR (PENGGUNA) e-policy no:MA227332

IMPORTANT NOTICES NOTIS PENTING

Pursuant to Paragraph 5 of Schedule 9 of the Financial Services Act 2013, if you are
applying for this Insurance wholly for purposes unrelated to your trade, business or
profession, you have a duty to take reasonable care not to make a misrepresentation in
answering the questions in this Proposal Form. You must answer the questions in this
Proposal Form fully and accurately.
Menurut Perenggan 5 daripada Jadual 9 Akta Perkhidmatan Kewangan 2013, jika anda
memohon insurans ini sepenuhnya untuk tujuan yang tidak berkaitan
perdagangan,perniagaan atau profesion anda, anda mempunyai kewajipan untuk
mengambil langkah yang munasabah untuk tidak salah nyata dalam menjawab soalan-
soalan dalam Borang Cadangan ini. Anda dikehendaki menjawab soalan-soalan dalam
Borang Cadangan ini dengan lengkap dan tepat.

Failure to take reasonable care in answering the questions may result in avoidance of Kegagalan untuk mengambil langkah yang munasabah dalam menjawab soalan-
your contract of insurance, refusal or reduction of your claim(s), change of terms or soalan, mungkin mengakibatkan pembatalan kontrak insurans anda, keengganan atau
termination of your contract of insurance. pengurangan gantirugi, perubahan terma atau penamatan kontrak insurans anda.

The above duty of disclosure shall continue until the time your contract of insurance is Kewajipan pendedahan diatas hendaklah diteruskan sehingga kontrak insurans anda
entered into, varied or renewed with us. dimeterai, diubah atau diperbaharui dengan kami.

In addition to answering the questions in this Proposal Form, you are required to Sebagai tambahan kepada soalan-soalan dalam Borang Cadangan ini, anda
disclose any other matter that you know to be relevant to our decision in accepting the dikehendaki untuk mendedahkan apa-apa perkara lain yang anda tahu akan
risks and determining the rates and terms to be applied. mempengaruhi keputusan kami dalam menerima risiko dan menentukan kadar dan
terma yang dikenakan.
You also have a duty to tell us immediately if at any time after your contract of Anda juga mempunyai kewajipan untuk memberitahu kami dengan serta-merta jika
insurance has been entered into, varied or renewed with us any of the information given pada bila-bila masa selepas kontrak insurans anda ditandatangani, diubah atau
in this Proposal Form is inaccurate or has changed. diperbaharui dengan kami, apa-apa maklumat yang dinyatakan dalam Borang
Cadangan ini tidak tepat atau telah berubah.

CBC REGULATION - Section 84(1) of the Financial Services Act 2013 PERATURAN CBC - Seksyen 84(1) daripada Akta Perkhidmatan Kewangan
2013
No licensed insurer shall assume any risk in respect of such description of policy as
may be prescribed by the Bank unless and until the premium payable is received by the Tiada penanggung insurans berlesen pun boleh mengambil alih apa-apa risiko
licensed insurer in such manner and within such time as may be prescribed by the berkenaan dengan apa-apa perihalan polisi sebagaimana yang ditetapkan oleh Bank
Bank. melainkan jika dan sehingga premium yang kena dibayar diterima oleh penanggung
insurans berlesen itu dengan apa-apa cara dan dalam apa-apa tempoh sebagaimana
yang ditetapkan oleh Bank.
Average Clause Fasal Purata
If your motor vehicle at the time of any loss or damage (be it partial/total loss) insured Sila pastikan anggaran nilai kenderaan anda yang dilindungi selaras dengan nilai
against be of greater value than the insured value stated in the policy, you shall be pasaran kenderaan tersebut. Jika tidak,mengikut 'Fasal Purata' anda terpaksa
considered as being your own insurer for the difference and shall bear a rateable menanggung sendiri sebahagian daripada kerugian yang dialami.
proportion of the loss accordingly. However, this clause shall not apply unless the Walaubagaimanapun, 'Fasal Purata' tersebut tidak akan dikenakan jika nilai yang
market value at the time of the loss exceeds the insured value by 10%. diinsuranskan melebihi 10% dari nilai pasaran semasa kerugian dilaporkan.

Passenger Liability Cover Perlindungan Liabiliti Penumpang

Please note that it is an offence under the laws of the Republic of Singapore to enter Adalah menjadi satu kesalahan di bawah undang-undang Republik Singapura untuk
the country without extending passenger liability cover to your motor insurance. memasuki negara tersebut tanpa perluasan perlindungan liabiliti penumpang ke atas
insurans motor Anda. Jika Anda membuat perjalanan ke Singapura, Anda mesti
mengambil perlindungan liabiliti ini.

A.THE PROPOSER/BUTIR PENCADANG

Name /Nama: LEE KONG CHENG
Address / Alamat : 20-5-7 PANGSAPURI SRI JINJANG JALAN
19/32 TAMAN JINJANG BARU
52000 KUALA LUMPUR
WP KUALA LUMPUR
Old IC No. or Bus. Regn No./No. K.P Lama atau No. Pendaftaran Perniagaan:
New IC No./No. K.P Baru: 780831-14-5367 Date of Birth /Tarikh Lahir: 31-08-1978
Gender or Body Corporate/Jantina atau Badan Koperat : MALE Nationality /Warganegara: MALAYSIAN

Marital Status/Taraf Perkahwinan: SINGLE Occupation/Pekerjaan: OTHER OCCUPATION

B. SCOPE OF COVER/SKOP LINDUNGAN

Period of Insurance/Tempoh Insurans:From/Dari : 20-09-2018 12:00:01 AM To /Hingga : 19-09-2019 12:00 midnight / tengah malam
Type of Insurance Required/Jenis Perlindungan Dipohon: PRIVATE VEHICLE - EXCLUDING GOODS - COMPREHENSIVE
Purpose for which vehicle is used/Kenderaan digunakan bagi tujuan: INDIVIDUAL

Page 9 18-09-2018 01:12:37 PM

C. DESCRIPTION OF VEHICLE /BUTIR-BUTIR KENDERAAN
Make/Buatan: PROTON Model /Jenis : PROTON SAGA
Variant/Varian: SE-0.0-4D SEDAN-4 SP NVIC: HKM09H
AUTOMATIC
Year of Manufacture/Tahun Diperbuat: 2009 Body Type /Jenis Badan: 4D SEDAN
Reg No./No. Pendaftaran: WSP3909 Cubic Capacity /Kuasa Enjin: 1332 CC
Engine No./No. Enjin: 34PEP53683 Chassis No. /No. Casis: PL1BT3SNR98091231
Agreed Value/Nilai yang dipersetujui RM 14,000.00 Seating Capacity/Muatan duduk: 5
Trailer's Reg No./No. Pendaftaran Treler: - Trailer Sum Insured/Jumlah Treler Diinsuranskan: RM 0.00
Date of Purchase/Tarikh Pembelian: - Purchase Price/Harga Pembelian: RM 0.00
Veh.Solely Use in/Kenderaan hanya digunakan di: WEST MALAYSIA Hire Purchase Owner/Pemilik Sewa Beli: -
Extra Benefits/Manfaat Tambahan: ADDITIONAL NAMED DRIVER(S)

Authorised Driver / Rider / Pemandu yang dibenarkan/Penunggang : THE POLICY HOLDER

LEE KIM MENG (510225-06-5199)
KHOR PAU CHOO (570725-08-5860)

D.ADDITIONAL QUESTIONNAIRE/SOALAN-SOALAN TAMBAHAN

THEFT AND VEHICLE SECURITY/KECURIAN DAN KESELAMATAN KENDERAAN

1) Anti-Theft Device / Alat-alat pencegah kecurian :WITH MECH DEV: FACTORY ALARM
2) Safety Features / Ciri-ciri Keselamatan :ABS (NO AIRBAGS)
3) Vehicle Garage / Tempat kenderaan biasanya ditempatkan :LOCKED GARAGE

E. APPLICABLE TO GOODS CARRYING VEHICLE ONLY/UNTUK KENDERAAN PENGANGKUT BARANG-BARANG SAHAJA

Will the vehicle carry any of the following goods/Adakah kenderaan tersebut membawa barang-barang seperti berikut?
Petroleum products or Gasoline or Petrolchemical/Barangan petrol @ Corrosive liquids / Cecair Korosif :
Gasoline @ Petrolchemical:
Liquified gases/Gas Cecair: Toxic Substances / Barangan Toksik :
Gases under pressure/Gas (dalam bentuk tekanan): Hazardous Chemicals / Bahan kimia merbahaya :

F. DECLARATION/PENGAKUAN

I/We understand that it is my/our duty to take reasonable care not to make a misrepresentation in answering the questions in this Proposal Form and I/we hereby declare that
I/we have fully and accurately answered the questions above.
Saya/Kami faham bahawa menjadi tanggungjawab saya/kami untuk mengambil langkah yang munasabah untuk tidak salah nyata semasa menjawab soalan-soalan dalam
Borang Cadangan ini dan saya/kami dengan ini mengaku bahawa saya/kami telah menjawab dengan sepenuhnya dan dengan tepat soalan di atas.

Dated this day ofTarikh hari ini

PROPOSER/PENCADANG : DULY WITNESSED/SAKSI:

Signature /Tandatangan : Signature /Tandatangan :

Full Name/Nama Penuh : Full Name/Nama Penuh :
NRIC Number/No. K.P.: NRIC Number/No. K.P.:

Page 10 18-09-2018 01:12:37 PM

 Service Tax License No : W10-1808-31004734

INVOICE

LEE KONG CHENG Invoice No : UTRK-00243871-0918

20-5-7 PANGSAPURI SRI JINJANG JALAN
19/32 TAMAN JINJANG BARU Date : 18-09-2018
52000 KUALA LUMPUR
WP KUALA LUMPUR

Account No : 10003108
Class : MOTOR

Particulars

Policy No : MA227332

Period of Insurance : 20-09-2018 To 19-09-2019

Currency : RINGGIT MALAYSIA

Gross Premium : 312.84

312.84
Stamp Duty : 10.00

Total Excluding Service Tax : 322.84

Service Tax (6.00%) : 18.77

Total Amount Payable : 341.61

This is computer generated documents. No signatory is required .

Page 11 18-09-2018 01:12:38 PM